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SAOJ
SOUTH AFRICAN ORTHOPAEDIC JOURNAL
March 2019
Vol 18 • No 1
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South African Orthopaedic Journal Page 1
http://journal.saoa.org.za
SAOJ
SOUTH AFRICAN ORTHOPAEDIC JOURNAL
THE OFFICIAL JOURNAL OF THE SOUTH AFRICAN ORTHOPAEDIC ASSOCIATION
ISSN: 1681-150x March 2019 | Vol 18 • No 1
CONTENTS
4 CONFERENCES, COURSES AND SYMPOSIA 33 SPINE
Burden and profile of spinal pathology at a major tertiary
hospital in the Western Cape, South Africa
9 EDITORIAL
Miseer S, Mann T, Davis JH
Imperfect regulation of implants
Shipley JA
40 HIP
Incidence and risk factors for extended post-operative
13 MESSAGE FROM THE PRESIDENT
length of stay following primary hip arthroplasty in a
Big data and medicine
South African setting
Rajah L
Dlamini NF, Ryan PV, Moodley Y
15 PAEDIATRIC ORTHOPAEDICS
47 GENERAL
Body mass index and Blount’s disease:
Pharmaceutical management of bone catabolism:
a single academic hospital experience
the bisphosphonates
Kgoedi MN, Rischbieter P, Goller R
Raubenheimer EJ, Noffke CEE, Lemmer LB, Slavik T,
van Heerden WFP, Miniggio HD
21 TUMOURS AND INFECTIONS
Reactivation of chronic haematogenous osteomyelitis in
54 CPD QUESTIONNAIRE
HIV-infected patients
Siyo Z, Marais LC
26 Minimally invasive CT-guided excision of osteoid osteoma and
other small benign bone tumours: a single centre case series in
South Africa
Sluis Cremer T, Hosking K, Held M, Hilton TL
Access the Journal Online
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Page 2 South African Orthopaedic Journal
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SAOJ
SOUTH AFRICAN ORTHOPAEDIC JOURNAL
THE OFFICIAL JOURNAL OF THE SOUTH AFRICAN ORTHOPAEDIC ASSOCIATION
ISSN: 1681-150x March 2019 | Vol 18 • No 1
Management Committee
President SAOA Treasurer SAOA Editor-in-Chief
Dr Leon Rajah Dr Stefan Colyn Prof Leonard Marais, Durban,
South Africa
Section Editors
Arthroplasty, Knee and Hip Spinal Surgery Paediatric Orthopaedics
M Held, Cape Town, South Africa RN Dunn, Cape Town, South Africa J du Toit, Cape Town, South Africa
C Snyckers, Pretoria, South Africa J Davis, Cape Town, South Africa G Firth, London, England
Trauma and General Orthopaedics Foot and Ankle Shoulder and Elbow
N Ferreira, Cape Town, South Africa N Saragas, Johannesburg, South Africa S Roche, Cape Town, South Africa
S Maqungo, Cape Town, South Africa G McCollum, Cape Town, South Africa C Anley, Stellenbosch University,
F Birkholtz, Pretoria, South Africa South Africa
Oncology and Infections
Hand Surgery TLB le Roux, Pretoria, South Africa Statistics and Research Methodology
A Ikram, Cape Town, South Africa T Hilton, Cape Town, South Africa M Burger, Cape Town, South Africa
D McGuire, Cape Town, South Africa
Editorial Board
A Schepers, Johannesburg, South Africa M Held, Cape Town, South Africa J Shipley, Bloemfontein, South Africa
F Birkholtz, Pretoria, South Africa LC Marais, Durban, South Africa GJ Vlok, Cape Town, South Africa
RN Dunn, Cape Town, South Africa MV Ngcelwane, Pretoria, South Africa J Walters, Cape Town, South Africa
Associate Editors Managing Editor
RB Bourne, Ontaria, Canada Patricia Botes, Johannesburg, South Africa Official publication of
JJ Dias, Leicester, United Kingdom pat@saoj.co.za The South African Orthopaedic
S Eisenstein, Oswestry, United Kingdom Association (SAOA)
BF Morrey, Rochester, USA
TD Peabody, Chicago, USA
Published by: Advertising queries: Subscriptions:
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Publication Information: The South African Orthopedic Journal (SAOJ) is an open-access journal that is published quarterly in print (ISSN 1681-150X) and is available
online from SciELO SA at http://www.scielo.org.za/scielo.php?lng=en (ISSN 2309-8309). Further information regarding the journal is available on the Association’s website
http://journal.saoa.org.za.
Policies: Authors of articles published in the The South African Orthopedic Journal retain the copyright of their articles without any restrictions. Authors retain publishing
rights and are free to reproduce and disseminate their work. Authors requiring a variation of this policy should inform the journal during the submission of their article.
All content is licensed under a Creative Commons Attribution 4.0 International Public Licence (CC BY 4.0). This licence facilitates open access by allowing free immediate
access to, and unrestricted reuse of, original work. The view expressed by contributors to the journal and the inclusion or exclusion of any medicine or procedure, do
not necessarily reflect the views of the publisher or the editors. While every effort is made to ensure accurate reproduction, the authors, editors, publishers and their
employees or agents shall not be responsible or in any way liable for errors, omissions or inaccuracies in the publication, whether arising from negligence or otherwise or
for any consequence arising therefrom. All journal policies can be viewed at http://journal.saoa.org.za.
The appearance of advertising in this publication does not denote a guarantee or an endorsement by SAOA of the products or the claims made for the products by
the manufactures.
Instructions for Authors and Reviewers: Comprehensive guidelines are provided at http://journal.saoa.org.za
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what did they become? International Orthopaedics (SICOT). 41. 47-51. 2017. (Survival with endpoint stem failure for any reason)
3. Clauss , M. et al. Fixation and loosening of the cemented Muller straight stem: a long-term clinical and radiological review.
The Journal of Bone and Joint Surgery [Br]. 91(B).1158-63. 2009. (Survival with endpoint stem revision for any reason)
4. McLaughlin, J.R. et al. Uncemented Total Hip Arthroplasty With a Tapered Femoral Component: A 22- to 26-year Follow-up
Study Orthopaedics Today. 30(1): 1. 2010. (Survival with endpoint stem revision for aseptic loosening)
5. McLaughlin, J.R. et al. Long-Term Results of Uncemented Total Hip Arthroplasty with the Taperloc Femoral Component
in Patients with Dorr Type C Proximal Femoral Morphology. The Bone & Joint Journal. 98-B:595-600, 2016. (Survival with
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All content herein is protected by copyright, trademarks and other intellectual property rights, as applicable, owned by or licensed
to Zimmer Biomet or its affiliates unless otherwise indicated, and must not be redistributed, duplicated or disclosed, in whole
or in part, without the express written consent of Zimmer Biomet. This material is intended for health care professionals.
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Page 4 South African Orthopaedic Journal
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Page 4
CONFERENCES, COURSES & SYMPOSIA
CONFERENCES, COURSES & SYMPOS
LOCAL MAY 2019
EUROSPINE Spring Specialty Meeting 2019
19th Congress of The South African Spine LOCAL FE
02 May 2019 – 03 May 2019
Society Frankfurt am Main, Germany
Be
30 May 2019 – 01 June 2019 SASSH (SA Society for Surgery of the Hand)
CSIR International Convention Centre, Pretoria Refresher Course
32nd Annual Meeting of the European Musculo
Congress organiser: Hendrika van der Merwe, Skeletal Oncology
23-25 February 2018 Society – EMSOS Florence
tel: +27 (0)21 981 3081; website: congress@saspine.org Pretoria
2019 Pa
15 May 2019 – 17 May 2019
Combined 65th South African Orthopaedic 18th Florence,
Congress ItalySA Spine Society
Congress 2019 – ‘Unity in Diversity’ 24-26 May 2018
02 September – 06 September 2019 35Elangeni
th Hotel,
Annual Durban Cervical Spine
Meeting Research Sc
ICC Durban Society – Rome 2019
Includes the following sub-specialty groups:
22 May 2019 – 24 May 2019
1. SA Arthroplasty Society (SAAS) 64Rome,
th
Congress
Italy of the South African
2. SA Knee Society (SAKS) Orthopaedic Association
3. SA Shoulder and Elbow Surgeons (SASES)
En
3-6 September
IACES 2018
2019 – Madrid International Advanced
4. SA Foot Surgeons’ Association (SAFSA) CSIR, Pretoria
5. SA Orthopaedic Trauma Society (SAOTS) Course on Elbow Surgery
6. SA Paediatric Orthopaedic Society (SAPOS) 23 May 2019 – 25 May 2019
7. SA Society for Hip Arthroscopy (SASHA) Madrid, Spain
8. Launch and inaugural meeting of the SA Orthopaedic
Oncology and Limb Preservation Society (SOLS) INTERNATIONAL
JUNE 2019 M
Contact: Chairman of the SAOA Congress Committee:
8th International Congress of Arthroplasty
Dr Ian Stead, email: iwstead@gmail.com JANUARY 20182019
Registries ISAR
AA
01 June 2019 – 03 June 2019
INTERNATIONAL 2nd International Consensus Meeting
Leiden, Netherlands
on Orthopaedic Infections
25 January 2018 - 26 January 2018 Ki
APRIL 2019 ISAR 2019
Philadelphia, United States
01 June 2019 – 03 June 2019
5 International Knee Update
th Leiden, Netherlands
Focus on Arthroplasty Symposium:
04 April 2019 – 06 April 2019 Unicondylar Knee Replacement Ut
Davos, Switzerland 2926th January
Conference of the European Wound
2018 - 27 January 2018
Management Association
Frankfurt am Main, Germany – EWMA 2019
ICJR 7th Annual Revision Hip & Knee Course – 05 June 2019 – 07 June 2019
Rochester 2019 19th Gothenburg,Sweden
Annual AAOS/AANA/AOSSM An
04 April 2019 – 06 April 2019 Sports Medicine Course Re
Rochester, United States 1431th January
IFSSH2018
and-11th IFSHT2018
04 February Triennial Congress
Berlin 2019
Park City, United States
Utrecht Spine Course Spinal Trauma 2019 17 June 2019 – 21 June 2019
12 April 2019 – 13 April 2019 Berlin, Germany 12
Utrecht, Netherlands
Me
12
2nd International Conference on Orthopedics,
Rheumatology and Osteoporosis
15 April 2019 – 16 April 2019
12
Milan, Italy
Au
Atlanta Trauma Symposium 2019
18 April 2019 – 20 April 2019
Atlanta, United States Eu
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South African Orthopaedic Journal Page 9
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EDITORIAL
Imperfect regulation of implants
Prof JA Shipley
MMed Orth UFS, FC Orth SA, Emeritus Professor of Orthopaedics, University of the Free State,
Bloemfontein, South Africa; shipleyja@gmail.com
Towards the end of last year, a prominent UK newspaper carried Medical implants in the USA are licensed by a single body, the
a leading article ‘Revealed: faulty medical implants harm patients reputable FDA, although the process is slow. But in the EU there
around the world’.1 This was followed shortly after by a BBC is no overall regulator; and a ‘CE mark’ of approval can be issued
News article on the same subject.2 The Implant Files Project, an by any one of 58 ‘Notified bodies’. These are non-governmental
international group coordinated by the International Consortium companies, and if one declines approval of a product, application
of Investigative Journalists, published some impressive statistics may be made at another one with no need to disclose the rejection
about implant problems. The main targets were meshes for elsewhere. Regulation in the EU is due to be upgraded in 2020,
pelvic floor and hernia reconstruction, breast implants, cardiac but apparently there is doubt as to how effective this will be. The
pacemakers and a contraceptive, but orthopaedics did not escape Medicines Control Council of South Africa is the official regulator in
unscathed. Problems with total hip, knee and intervertebral this country but it is dysfunctional.
disc replacements also featured prominently. Even allowing for So should we simply rely on European or USA licencing for
journalistic dramatisation and over-simplification, the figures protection even though their processes are open to criticism? I
quoted are worrying. Between 2015 and 2018, 62 000 adverse think this would be a mistake for two main reasons and believe
events with implants were reported in the UK alone, a third of them that that we need to evaluate any implant under South African
causing serious complications, including 1 004 deaths. In the USA conditions, while remaining alert for problems encountered in other
the FDA recorded 5.4 million events over the past decade, with countries. My first reason is that different countries have different
500 000 implants requiring removal, and 83 000 deaths. profiles of patients and implant use, and different surgical traditions
Prof Derek Alderson, the president of the Royal College of or preferences, often regional. This may skew results in different
Surgeons, was quoted as saying there had been enough incidents locations, such as our country, and local registers are needed to
involving flawed devices to ‘underline the need for drastic identify poor performers. There is a second important aspect.
regulatory changes’, including the introduction of mandatory Implant problems can be divided into design errors, which would
national registries for all implantable devices. apply to every implant used, and manufacturing problems where a
‘In contrast to drugs, many surgical innovations are introduced certain batch of implants may be flawed for some reason. Design
without clinical trial data or centrally held evidence,’ he said. ‘This errors in devices from reputable manufacturers will become obvious
is a risk to patient safety and public confidence.’ in time, especially in countries where large numbers of the implant
Three years ago, I wrote in an editorial for this journal, ‘New are used and registers are kept. This would allow recognition of
techniques need to be validated independently before, not after, a problem implant irrespective of where it is used. Manufacturing
they are released on the market. And as commercially naïve, problems and implants from little known manufacturers may be
enthusiastic and adventurous surgeons we must learn not to different, however. In a small market like South Africa, it would be
confuse novelty with progress’. I still feel the same, and think we quite possible for an occasional sub-standard batch of implants
need improved enforcement of the present imperfect regulation of from a recognised company to form a substantial proportion of
implants. an importer’s order. This would cause a localised problem with
an implant that is not noticeable against the background of its
The criticisms of the present system can be reduced to the success elsewhere, and would only be picked up by a register in
following: the area where they are concentrated. Another problem is the use
• absence of independent clinical trials of implants in humans (as of cheap implants from unknown sources often in the Far East.
opposed to pigs!) before their release on the market They usually have no history of performance and are imported by
• failure of manufacturers to respond constructively to complaints opportunistic entrepreneurs, often to supply a Provincial tender.
about their products Again, any low-cost devices that are below standard would only be
• failure of manufacturers to reveal previous rejections by recognised if their use is recorded and tracked. So South African
regulatory bodies when making application to a new body implant registers may be very important for the identification of
• considerations of commercial confidentiality obstructing such problem batches or imports, and the patients who are at risk
enquiries following their use.
• acceptance by a regulatory body of an implant on the grounds I agree with Prof Alderson that mandatory registers for all
of approval by another regulator, or similarity to another implant, implants have become necessary. South African implant registers
without performing an independent evaluationPage 10 South African Orthopaedic Journal
http://journal.saoa.org.za
would certainly make a contribution to the global experience,
but they are probably more valuable for their ability to recognise
inappropriate implant use and manufacturing defects in this region.
The government cannot be expected to organise this without our
help, and it would be ridiculous to expect the fiercely competitive
orthopaedic industry to police itself. I believe the onus is on
each surgeon to record his implant use in a register owned and
administered by the respective professional body – in our case the
SAOA and its sub-groups. We are all aware of past problems in
South Africa with arthroplasty registers, and this would probably
need some form of legislation to motivate our less compliant
colleagues. As a back-up, the hospital groups should also be
made responsible for recording implant use, including details of
the patient and surgeon. Costs could be recovered from a small
levy added to the price of each implant. The medical aids could be
expected to support such registers as they would benefit financially
from identifying and eliminating substandard hardware and their
attendant complications. Medical aid and hospital administration
systems could certainly be programmed to record and forward
data to central registers at minimal cost and inconvenience to all
concerned.
I have written this editorial as one with no experience of implant
registers or the practical problems around them. I realise this is
a controversial subject but I hope that a dispassionate, objective
examination of the matter will result in increased understanding
and support for the SAOA and the leaders in our speciality in
their efforts to achieve this ideal. I believe we have a professional
obligation to do so.
References
1. The Guardian. 5 November 2018
2. BBC Health News 25 November 2018Preventing and reducing periprosthetic joint infections
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All content herein is protected by copyright, trademarks and other intellectual property rights, owned by or licensed to
Zimmer Biomet or its affiliates unless otherwise indicated, and must not be redistributed, duplicated or disclosed, in whole or
in part, without the express written consent of Zimmer Biomet.
For complete product information, including indications, contraindications, warnings, precautions, potential adverse effects
and patient counselling information, see the package insert and www.zimmerbiomet.com.
Check for country product clearances and reference product specific instructions for use.
Document not for distribution in France. Not intended for surgeons practicing medicine in France.
© 2017 Zimmer Biomet
os Modular System- Advert Jan 2017.indd 1 1/25/17 11:26 AMSouth African Orthopaedic Journal Page 13
http://journal.saoa.org.za
MESSAGE FROM THE PRESIDENT
Big data and medicine
Leon Rajah
FCS(SA)Orth
President: SA Orthopaedic Association
‘We are on the verge of a digital revolution across every aspect of
this sector, from the lab bench to the patient’s bed side’.1,2
Purpose
There are two distinctive features of big data analysis. The first is
It is predicted that three emerging technologies will drive the next
the inductive nature of big data systems – analysis of a massive
wave of medical innovation:
number of data points to identify patterns that prompt hypothesis
1. Internet of things: For example, wearable devices can track
measures such as walking speed, balance and movement. generation; this in contrast to the conventional research method of
Such real-time data provides a better understanding of disease using data to validate a human hypothesis. The second is that big
progression and impact of treatment. data approaches are correlational. Big data does not demonstrate
2. Artificial intelligence (AI) and machine learning: These causality, is agnostic to cause and has been criticised for lacking
technologies will revolutionise the way we interrogate data. causal explanatory value.
3. Emerging data platforms: These will allow unprecedented This is not a new argument: in 1847 the hygienist Semmelweist
computing power and advances in data management systems identified that hand washing with chlorine in maternity wards
for analysis and insight generation referred to as big data. dramatically decreased mortality rates.3 Most of his colleagues
rejected the findings (he inferred an incorrect underlying cause)
Big data refers to the analysis of massive amounts of data points to
and resisted hand washing with chlorine, causing the unnecessary
gain novel insight; and its key characteristics may be understood by
deaths of tens of thousands. Big data insights are going to raise
considering data, method and purpose.3
similar issues in the future: What is sufficient evidence to act? How
high is the burden of proof?
Data The approaches need not be exclusionary. In a recent study of
Alzheimer’s disease, millions of variables were measured following
Big data is a massive shift in the ability to collect and analyse data
DNA and RNA sequencing in different brain regions. Conclusions
quickly and cheaply. In the future we will routinely collect and
were reached by allowing the data to speak to a likely driver of
analyse massive data sets from a larger number of individuals
relevant to a phenomenon; and when possible, analyse all data disease. The data analysis identified the immune system and
collected, rather than just data samples. microglial cells as a key driver of disease (as opposed to traditional
With big data, volume may be traded off against quality. The concepts relating to tangles or plaques).7 This raised possible
‘unreasonable effectiveness of data’ maintains that heterogeneous novel therapies, which may be evaluated using hypothesis-testing
sources for data of limited quality may be better if one generates in prospective randomised controlled trials. Big data may herald
a huge amount of it, compared to only a small amount of data at a change to a more staged discovery process – with correlational
high quality.3 Using comprehensive data leads us to ask a further results and ensuing causal inquest.
question: when do we stop collecting data and what do we do with The usefulness of the big data approach in health care remains
‘new’ data? Big data suggests tentativeness; learning is a summary disputed, however – does it provide a future with novel insights or
of what is known of a dynamic phenomenon and necessitates re- does it create more noise that drowns out true signals? Jacofsky
evaluation at regular intervals. refers to these as: a lack of data set reliability and clarity; a
preponderance of unstructured data; ineffective and inaccurate
Method measures transposed to manage the behaviour of providers and
income from payer claims or coders; a lack of intersystem reliability
A big data approach requires the use of AI and its application to and inconsistent value of output from a system (analogous to a
machine learning.4-6 AI refers to the ability of a machine to perform calculator providing a different answer to the same calculation).8
cognitive functions usually associated with the human mind Big data can impose the same challenges as small data; and adding
(perception, reasoning, learning and problem solving). Machine more data without physicians to control and standardise definitions
learning is the application of AI to massive data sets using complex
will most often not solve but merely magnify the problem.
self-learning algorithms to detect patterns, make predictions and
generate hypotheses. The potential of AI is enormous: In 2017,
Google’s Alpha Zero Program Self-Learning AI chess programme Conclusion
taught itself chess with no human instruction, and after only 8 hours
beat the then reigning 2016 World Computer Chess Champion Big data enthusiasts propose that medicine has changed to an
Stockfish 8. information science.9 Popular literature declares the physicalPage 14 South African Orthopaedic Journal
http://journal.saoa.org.za
examination of a patient redundant.10 In our prime directive – ‘the
only interest to be served is the interest of the patient’ – is embedded
that human spirit to defend the integrity of clinical practice, thought
and innovation; and posit clinical medicine as integral to a defence
against a future dominated by digital dictatorship, financial oligarchy
and human redundancy.11,12
References
1 3 things that will change medicine in 2018. Vasant Narasimhan,
CEO, Global Head, Drug Development; Novartis AG; World
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Healthcare; 24 Jan 2018.
2 The Economist editorial: A revolution in health care is coming
Welcome to Doctor You; 1st February 2018.
3 Mayer-Schonberger & Ingelsson. Big Data and medicine: a big
deal? Journal of Internal Medicine, 2018;283:418-29.
4 Hawking S. Brief Answers to the Big Questions. John Murray
Publishers, Great Britain, 2018.
5 An executive’s guide to AI. McKinsey Analytics, McKinsey &
Company, 2018.
6 Domingos P. Our digital double: AI will serve our species, not
control it. Scientific America special issue: The Science of being
Human; September 2018.
7 The role of big data in medicine: Interview with Dr Eric Schadt
of the Icahn Institute for Genomics and Multiscale Biology at
New York’s Mount Sinai Health System by Sastry Chilukuri for
McKinsey and Company; November 2018.
8 Jacofsky DJ. Instructional Review: The myths of ‘big data’ in health
care. Bone Joint J 2017;99-B:1571-76.
9 Krumholz HM. Big data and new knowledge in medicine: the
thinking, training, and tools needed for a learning health system.
Health Aff (Millwood). 2014 July;33(7):1163-70. doi:10.1377/
hlthaff.2014.0053
10 Kraft D. ‘Connected’ and high-tech: your medical future. National
Geographic special issue: The Future of Medicine; January 2019.
11 Varoufakis Y. Talking to my daughter about the economy a brief
history of capitalism. Penguin Random House Publishers; United
Kingdom 2017.
12 Harari YN. 21 Lessons for the 21st Century. Penguin Random
House Publishers, United Kingdom 2018.South African Orthopaedic Journal Kgoedi MN et al. SA Orthop J 2019;18(1)
http://journal.saoa.org.za DOI 10.17159/2309-8309/2019/v18n1a1
PAEDIATRIC
TRAUMA ORTHOPAEDICS
Body mass index and Blount’s disease:
a single academic hospital experience
Kgoedi MN¹ , Rischbieter P², Goller R³
1 MBChB(UFS); Registrar Orthopaedic Surgery, University of Pretoria, Pretoria, South Africa
² MBChB(UP); Registrar Radiology, University of Pretoria, Pretoria, South Africa
³ MBChB, FCS Ortho(SA), MMed(Ortho); Specialist Orthopaedic Surgeon, Department of Orthopaedic Surgery, University of Pretoria, Pretoria,
South Africa
Corresponding author: Dr MN Kgoedi, Orthopaedic Department Level 7, Steve Biko Academic Hospital, cnr Steve Biko Road and Savage Street,
Gezina, Pretoria, 0001; email: nelsonkgoedi@gmail.com; tel: +27 12 354 2851
Abstract
Background: Blount’s disease is a developmental disorder of the proximal tibia with progressive varus, flexion and internal rotation
deformity. It is often seen in overweight children and strongly associated with obesity. As the prevalence of childhood obesity is
increasing worldwide, the incidence of Blount’s disease has been noted to be on the increase as well. In the South African population,
most children are malnourished with high levels of undernutrition compared to other middle-income countries. We hypothesised that
in our institution, patients with Blount’s disease have a body mass index (BMI) lower than reported in studies from mainly developed
countries. The aim of the study was to investigate the relationship between BMI and Blount’s disease in a South African academic
institution.
Methods: All clinical and radiological records of patients with Blount’s disease at a tertiary hospital in South Africa over a six-year
period were retrospectively reviewed. Five patients did not meet inclusion criteria and were excluded from the study. Data collected
included patients’ demographics, weight, height and radiological investigations. A control group of randomly selected paediatric
orthopaedic patients was studied.
Results: A total of 39 Blount’s patients (19 females, 20 male) were studied. All the Blount’s patients were of black ethnicity. There were
nine patients with early-onset and 30 patients with late-onset Blount’s disease. The mean BMIs for Blount’s disease and control groups
were 26 kg/m² and 20 kg/m² respectively (pPage 16 Kgoedi MN et al. SA Orthop J 2019;18(1)
Introduction The purpose of this study was to investigate the BMI profile and
demographics of patients with Blount’s disease in the South African
Blount’s disease is a developmental condition characterised by context and determine the relationship between body weight
disordered endochondral ossification of the medial part of the and Blount’s disease and the severity of angular deformities. We
proximal tibial growth plate resulting in multi-planar deformities hypothesised that in our institution, patients with Blount’s disease
of the lower limb.1,2 Secondary to the asymmetrical growth with have a higher BMI than the general paediatric population, but still
relative inhibition of the posteromedial portion of the proximal tibial lower than reported studies from mainly developed countries. The
growth plate, a three-dimensional deformity of the tibia develops second hypothesis was that increasing BMI is associated with
with varus, procurvatum (apex anterior), and internal rotation along worsening angular deformities.
with possible limb shortening in unilateral cases.1,2 This entity
can lead to a progressive deformity with gait abnormalities, limb- Material and methods
length discrepancy, and premature arthritis of the knee.1,2 Blount’s
disease is classified into early-onset (infantile) and late-onset A retrospective review of clinical and radiological records was
based on whether the limb deformity develops before or after the conducted of all patients with Blount’s disease that attended the
age of four years.2-4 It is classified radiologically by Langenskiold Paediatric Orthopaedic Unit from 1 January 2011 to 31 December
into six progressive stages per severity of the deformity to help 2016. Patients’ details were obtained from the surgical database
in prognosticating patients’ outcome.4-7 The incidence of Blount’s and outpatient records. Patients’ folders were retrieved from the
disease in South Africa was estimated to be 0.03% three decades records department. Radiological images of all patients were
ago.8 available from the hospital’s picture archiving and communication
The aetiology of Blount’s disease remains unknown, though system (PACS). All patients diagnosed with Blount’s disease were
multifactorial origin is proposed with genetic and mechanical included in the study. Patients were grouped into four ethnicities,
components contributing to its development.3 There is a i.e. black, white, coloured and Indian. Incomplete clinical records,
predisposition of black children to develop Blount’s disease other congenital abnormalities and patients over 20 years of age
compared to other racial groups.3 Blount’s disease has been linked were excluded from the study.
to increasing weight and vitamin D deficiency.1,2,9,10 A number of A randomised control group of 100 paediatric orthopaedic
studies show a strong correlation between Blount’s disease and patients was included in the study to achieve a ratio of at least 2:1
obesity.3,10-14 Lisenda et al. found no independent association for statistical analysis. This included patients that were treated for
between vitamin D deficiency and Blount’s disease in their study injuries with clinical records of weight and height. Patients with other
in South African children.15 Obesity has been shown to greatly congenital abnormalities/deformities and patients over 20 years of
increase the medial compartment pressure and contribute to age were excluded from the control group. A simple randomisation
the development of Blount’s disease by the Heuter-Volkmann method was utilised to obtain a representative sample of the
principle.16 control group from 1 January 2016 to 31 December 2016. The
Limited research is inconclusive on the relationship between control group consisted of patients seen in 2016, grouped by sex.
increasing body mass index (BMI) and the severity of Blount’s Each was allocated a number and a random number generator
disease deformity.11,13 A strong correlation has been found only was utilised to obtain a sample of 50 patients for each sex. BMIs
between morbid obesity and radiological deformities of early- were calculated from the patients’ weight and height records. The
onset Blount’s disease.13 As the prevalence of childhood obesity is BMIs were interpreted as follows: 30 kg/m2 as obese.9 BMI percentiles (BMI%) were plotted using
patients by Sabharwal et al., the average BMI was 35.6, with the the 2000 Centre for Disease Control and Prevention age- and sex-
average BMI of 29.2 for early-onset and 39.7 for late-onset Blount’s specific charts for every patient.
disease.13 Patients’ radiological images were studied for classification of
Childhood obesity has doubled in the past three decades. The Blount’s disease using the Langenskiold classification system. This
percentage of children aged 6–11 years who were obese increased is a staging system of Blount’s disease according to the degree
from 7% in 1980 to nearly 18% in 2012 in the United States.17 of metaphyseal–epiphyseal changes seen on radiographs used
Similarly, the percentage of adolescents aged 12–19 years who to prognosticate outcomes.2,4,5 Stage I is defined as presence
were obese increased from 5% to nearly 21% over the same of medial epiphyseal beaking; stage II is described as a saucer-
period.17 In 2012, more than one-third of children and adolescents shaped defect of medial metaphysis; stage III is when the saucer
were either overweight or obese.17 It has been estimated that over defect deepens into a step; stage IV is when the epiphysis is bent
22 million children under the age of 5 years are obese worldwide.18 down over the medial beak; stage V when there is the presence
The prevalence of being overweight in Africa and Asia averages of a double epiphysis; and stage VI when there is development of
below 10% while in America and Europe it averages above 20%.18 a medial physeal bony bar.2,4,5 These were further categorised as
In the South African population, many children are malnourished low grade (Langenskiold stages I–IV) and high grade (Langenskiold
compared to other middle-income countries.19-23 Micronutrient stages V–VI) Blount’s disease.7,25
malnutrition is regarded as a public health problem of considerable Tibio-femoral angles (TFA) were calculated on the PACS images
significance in South Africa.19,22,23 South African children aged and recorded for each patient. X-rays were full weightbearing with
1 to 9 years have an intake of less than 67% of the recommended the patella facing forward. All data collected was recorded onto
dietary allowances (RDAs) for energy, calcium, vitamin D and other Microsoft Excel spreadsheet for analysis. Ethics approval was
micronutrients.19,22,23 In a national study conducted in 2004, 10% of obtained prior to commencement of the study.
children were classified as overweight and 4% as obese in South
Africa.22 The Health of the Nation Study, estimated an increase in Statistical methods
overweight from 1.2% to 13% and in obesity from 0.2% to 3.3%
over the period from 1994 to 2004, and more recent studies The descriptive statistics were used with the assistance of a
showed a mean prevalence of just over 15% for overweight and statistician. Standard deviation and ranges, with 95% confidence
obesity combined.24 intervals for body mass indices in children with Blount’s disease andKgoedi MN et al. SA Orthop J 2019;18(1) Page 17
Table I: Summary of Blount’s patients’ demographic data
Early Late Total
Number of patients 9 30 39
Sex
Male 4 16 20
Female 5 14 19
Laterality
Unilateral 4 16 20
Bilateral 5 14 19
Langenskiold classification
Stage I 2 0 2
Stage II 9 7 15
Stage III 6 1 7
Stage IV 0 11 11
Stage V 1 14 15
Stage VI 0 8 8
Table II: Mean BMI values of the subgroups of Blount’s disease patients Results
Mean BMI P-value
Forty-four Blount’s disease patients were identified. Five patients
Onset were excluded from the study (three had no weight and height
Early 24.2 0.459 records and two had no radiographs on PACS). Records and
radiographs of 39 patients were retrospectively analysed. There
Late 27.7
were 20 male patients and 19 female patients with a mean age of
Sex 7.5 years (range: 1–15). A summary of the patient data is given in
Male 27.7 0.4489
Table I. There was no difference in sex distribution of both early-
onset (infantile) and late-onset (juvenile and adolescent) Blount’s
Female 25.3 disease patients. The mean age was 3 years (range: 2–4) for early-
Laterality
onset Blount’s disease and 10 years (range: 5–17) for late-onset
Blount’s disease patients. All Blount’s disease patients were of
Unilateral 23.2 0.0275 black ethnicity. A total of 100 control patients were studied. The
Bilateral 29.9 control group had 50 male and 50 female patients with a mean age
of 8.4 years (range: 2–17).
The mean BMI for Blount’s disease patients was 26.5 kg/m2
Table III: Classification of Blount’s patients and the control group based (range: 12–44) with early-onset Blount’s patients having a mean of
on BMI percentile ranges (CDC 2000 percentile chart) 24.2 kg/m2 (range: 12–44) and 27.7 kg/m2 (range: 12–43) for late-
Percentile Blount’s Control Total onset Blount’s patients (Table II). There was no statistical difference
between the mean BMI of early-onset and late-onset Blount’s
95th (obese) 59% (23) 40% 45.32% respectively (p=0.4489).
There was no association between laterality and onset of Blount’s
Fisher’s exact = 0.002
disease (early vs late) with Pearson chi-squared = 0.22 with p-value
= 0.64 and Fisher’s exact = 0.72. There was a statistically significant
the control group were calculated. The t-test and Wilcoxon rank- difference between the mean BMI of patients with unilateral disease
sum (Mann-Whitney) test were used to determine differences in 23.2 kg/m2 (range: 12–40) and bilateral disease 29.9 kg/m2 (range
BMI between early-onset and late-onset Blount’s disease children. 13–44) with p-value = 0.0275). The mean BMI for the control group
was 20.2 kg/m2 (range: 12–36). There was a statistically significant
Cross-tabulations of categorical variables with Fisher’s exact
difference between the mean BMI of Blount’s disease patients and
and chi-squared tests were done to assess for associations. The the control group (p-value = 0.0005).
frequency distributions in terms of BMI and BMI% of early-onset Table III presents a comparison of BMI% between Blount’s
and late-onset Blount’s disease were compared using the chi- disease patients and the control group based on the CDC criteria
squared test. The two-sample Wilcoxon rank-sum (Mann-Whitney) for children (Fisher’s exact = 0.002). Five (56%) of nine children
test was used to determine statistically significant differences in with early-onset Blount’s disease and 18 (60%) of 30 patients with
BMI between the Blount’s disease group and the control group, late-onset Blount’s disease were classified as obese (Fisher’s exact
controlling for age. Pearson’s correlations were used to assess = 0.459). Five (17%) of the 30 patients with late-onset Blount’s
disease and none of nine patients with early-onset Blount’s disease
the relationship between BMI and angular deformity (TFA), and
were classified as overweight.
a univariate logistic regression model using BMI to predict the Using BMI values to interpret categories without controlling for
Langenskiold classification for severity was assessed. Significance age and sex shows that 31% of Blount’s patients are underweight
was determined at p-valuePage 18 Kgoedi MN et al. SA Orthop J 2019;18(1)
50
45
45
percentage of patients (%)
40 38
35 33
31
30
25 23
20
13 14
15
10
5 3
0
underweight normal overweight obese
BMI category
Blount's control
Figure 1. Body mass index categories of Blount’s disease patients and the control group
Figure 1. Body mass index categories of Blount’s disease patients and the control group
[Celeste please delete the text at the top of the figure]
Figure 3. Standing antero-posterior (AP) radiograph of a 9-year-old
Figure 2. Radiograph of a 3-year-old child with bilateral limb involvement, female patient with Langenskiold stage VI late-onset Blount’s disease of
early-onset Blount’s disease the right limbKgoedi MN et al. SA Orthop J 2019;18(1) Page 19
A total of 58 knees were studied radiologically (19 bilateral, Body mass index
20 unilateral disease). Examples of the cases are illustrated in
Figures 2 and 3. Using the Pearson correlations, no relationship The mean BMI values of our study population are significantly
was found between BMI and TFA (r=0.0342, p=0.8364). Using lower than those reported in the literature. A retrospective study
BMI to predict the Langenskiold classification for severity by the of 45 Blount’s disease patients by Sabharwal et al. found a mean
univariate logistic regression model, no association was found BMI of 35.6 kg/m2 with mean BMI of 29.2 kg/m2 for early-onset
between BMI and Langenskiold classification (p=0.453). The mean Blount’s disease and 39.7 kg/m2 for late-onset Blount’s disease.13
TFA was 26.88° (range: 12–50) for early-onset disease and 27.4° In our study, the mean BMI was 26.5 kg/m2 with a mean BMI of
24.2 kg/m2 for early-onset and 27.2 kg/m2 for late-onset Blount’s
(range: 4–54) for late-onset disease. Using cross-tabulation and
disease. Malnutrition and environmental effects may have
Fisher’s exact test to assess for an association between onset and
contributed to the difference.15,21-23
Langenskiold classification, eight of nine patients with early-onset
Blount’s had low-grade (I–IV) Blount’s disease (88.9%) whereas
56.7% of patients with late-onset Blount’s disease had high-grade
Race
(V–VI) Blount’s disease. This was statistically significant with Our study population with Blount’s disease consisted only of the
p=0.023. black race. Although a conclusion cannot be reached, there seems
to be a high predisposition of Blount’s disease in black children.
Discussion Rivero et al. found a greater prevalence of Blount’s disease among
black children, although this predisposition was stronger in late-
The results our cohort show that patients with Blount’s disease have onset Blount’s disease.3 A recent study by Lisenda et al. from South
a higher BMI compared to the general paediatric population. These Africa also found all the patients in their study to be of black race.15
results are comparable to studies reported in developed and other This forms a strong basis to suggest the relationship between black
developing countries. However, the mean BMI for Blount’s disease race and Blount’s disease.
patients was significantly lower than in the existing literature.13
Onset
Sex Our study had only nine (23%) early-onset Blount’s patients
In our study population, Blount’s disease affected both sexes compared to 30 (77%) late-onset Blount’s disease patients.
equally with a comparable number of unilateral and bilateral Although late-onset Blount’s patients had a higher mean BMI
compared to early-onset Blount’s disease, this was not found to
cases. Similarly, there was an equal presentation of both sexes
be statistically significant. These results are similar to a study by
in early-onset and late-onset Blount’s disease groups. A recent
Sabharwal et al. which found that early-onset Blount’s disease
meta-analysis by Rivero et al. found that patients with early-onset
patients have lower BMI values than late-onset Blount’s disease
Blount’s disease were more likely to be females than males (61%
patients.13
vs 39%; p=0.01).3 Inaba et al. in a multi-centre study in Japan
found that there were more females in both early-onset and late-
Severity
onset Blount’s disease.26 On the contrary, Montgomery et al.
found that Blount’s disease had a statistically significant positive Our study found no statistical difference in severity of angular
association with patient’s sex, with males 8.16 times more likely to deformity using TFA in both the early-onset and late-onset diseases
have Blount’s disease compared with females.10 Sabharwal et al. in and no association with BMI. Dietz et al. have investigated the
their study of 51 Blount’s disease patients also found more males relationship between obesity and angular deformities in 15 children
affected than females (32 males vs 19 females).27 Our study found diagnosed with Blount’s disease and found a strong relationship
that male patients had a higher mean BMI value than their female between body weight, TFA and varus deformities.13 In a study by
counterparts. Sabharwal et al. also found a higher BMI in males Sabharwal et al., a linear correlation was found between obesity and
than females (38.2 vs 32.1 p=0.07) in his study of 45 patients with radiographic changes in children with early-onset Blount’s disease
Blount’s disease.13 On the contrary, Pirpiris et al. found no statistical (r=0.74, p < 0.0001) and children with BMI values greater than
difference in BMI between males and females, with females having 40 kg/m2 who have late-onset Blount’s disease. No relationship was
slightly higher BMI values than males (24.6 kg/m2 in males vs found in late-onset Blount’s disease patients with BMIPage 20 Kgoedi MN et al. SA Orthop J 2019;18(1)
not be reached. Although increased BMI has a strong association 6. Laville JM, Chau E, Willemen L, Kohler R, Garin C. Blount’s
with Blount’s disease and probably influences the severity of disease: Classification and treatment. J Pediatr Orthop B. 1999
Jan;8(1):19-25.
angular deformities, other factors that may contribute to these
7. Khanfour AA. Does langenskiold staging have a good prognostic
changes were not assessed, i.e. vitamin D deficiencies and early value in late onset tibia vara? J Orthop Surg Res. 2012 Jun 7:23.
walking age although vitamin D deficiency was not found to be 8. Bathfield CA, Beighton PH. Blount’s disease. A review of
associated with Blount’s disease in a recent study.15 etiological factors in 110 patients. Clin Orthop Relat Res. 1978
Sep;135:29-33.
9. Gettys FK, Jackson JB, Frick SL. Obesity in pediatric
Conclusion orthopaedics. Orthop Clin North Am. 2011 Jan;42(1):95,105, vii.
10. Montgomery CO, Young KL, Austen M, Jo CH, Blasier RD, Ilyas
Our study demonstrates that our cohort with Blount’s disease has M. Increased risk of Blount’s disease in obese children and
a higher BMI than the control population at our institution. Contrary adolescents with vitamin D deficiency. J Pediatr Orthop. 2010
to existing literature, no relationship was found between sex, onset Dec;30(8):879-82.
or laterality and Blount’s disease in our study. There was also no 11. Pirpiris M, Jackson KR, Farng E, Bowen RE, Otsuka NY. Body
significant difference in BMIs between early-onset and late-onset mass index and Blount’s disease. J Pediatr Orthop. 2006
Sep-Oct;26(5):659-63.
Blount’s disease patients or the severity of the deformities. Although
12. Chan G, Chen CT. Musculoskeletal effects of obesity. Curr Opin
our study only had black patients, a larger multi-centre study is Pediatr. 2009 Feb;21(1):65-70.
required in the South African population to assess the relationship 13. Sabharwal S, Zhao C, McClemens E. Correlation of body mass
between race and Blount’s disease and to assess the genetic index and radiographic deformities in children with Blount’s
aetiology that may be responsible for the black racial predilection. disease. J Bone Joint Surg Am. 2007 Jun;89(6):1275-83.
Our findings support the association between BMI and Blount’s 14. Scott AC, Kelly CH, Sullivan E. Body mass index as a prognostic
factor in development of infantile Blount’s disease. J Pediatr
disease in children. Measures aimed at decreasing weight and thus Orthop. 2007 Dec;27(8):921-25.
childhood obesity may have some effect on the number of children 15. Lisenda L, Simmons D, Firth GB, Ramguthy Y, Kebashni T,
with this condition. Robertson AJ. Vitamin D status in Blount’s disease. J Pediatr
Orthop. 2016 Jul-Aug;36(5):e59-62.
Ethics statement 16. Guven A, Hancili S, Kuru LI. Obesity and increasing rate
The study was conducted after written approval from the Academic Hospital
of infantile Blount’s disease. Clin Pediatr (Phila). 2014
management. Approval from the University MMed committee was obtained. The
Jun;53(6):539-43.
Faculty of Health Science’s Ethics committee approval was obtained (Protocol 17. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood
number: 5/2017) prior to the commencement of the study. All patients’ records were and adult obesity in the United States, 2011-2012. JAMA. 2014
assigned a study number and no patient details were divulged in order to protect their Feb 26;311(8):806-14.
confidentiality. 18. Kosti RI, Panagiotakos DB. The epidemic of obesity in children
and adolescents in the world. Cent Eur J Public Health. 2006
Dec;14(4):151-59.
Declaration 19. Nutrition and South Africa’s children [homepage on the Internet].
The authors declare authorship of this article and that they have followed sound 2003 [cited 24 June 2016]. Available from: www.soulcity.org.za/
scientific research practice. This research is original and does not transgress projects/soul-buddyz/soul-buddyz.../nutrition-literature-review.
plagiarism policies.
20. 2000 CDC growth charts for the United States: Methods and
development [homepage on the Internet]. Hyattsville, Maryland:
Acknowledgements DHHS Publication No. (PHS) 2002-1696 May 2002 [cited 04 June
We wish to thank the staff at Paediatric Orthopaedic unit, for their continuous 2016]. Available from: www.cdc.gov/growthcharts/cdc_charts.htm.
dedication and management of these patients with Blount’s disease. 21. Overview: Child and Maternal Health [homepage on the Internet].
South Africa: UNICEF South Africa 2013 [cited 24 June 2016].
Available from: http://www.unicef.org/southafrica/survival_
Author contributions devlop_343.htm.
Kgoedi MN – main author, study conceptualisation, protocol preparation, collection 22. Labadarios D, Swart R, Maunder EMW, Kruger HS, Gericke
and interpretation of data and preparation of the manuscript GJ, Kuzwayo PMN. Executive summary of the national food
Rischbieter P – contributed to study conceptualisation, preparation of the protocol and consumption survey fortification baseline South Africa, 2005. The
collection of data South African Journal of Clinical Nutrition. 2008;21(3):245-300.
Goller R – study supervisor from study conceptualisation, review of protocol,
23. Labadarios D, Steyn NP, Maunder E, MacIntryre U, Gericke G,
preparation and revisions of the manuscript Swart R, et al. The National Food Consumption Survey (NFCS):
South Africa, 1999. Public Health Nutr. 2005 Aug;8(5):533-43.
ORCID 24. Hermanus A. Rossouw, Catharina C. Grant, Margaretha Viljoen.
Kgoedi MN http://orcid.org/0000-0002-5749-9960 Overweight and obesity in children and adolescents: The South
African problem. J Afr J Sci. 2012;108(5).
25. Wendee Morgan. Blount’s disease. [cited 03 August 2017]
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